Basic Information
| Provider Information | |||||||||
| NPI: | 1821009838 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LALL | ||||||||
| FirstName: | MADHULIKA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 420 E DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | FOND DU LAC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549354560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9209268340 | ||||||||
| FaxNumber: | 9209268370 | ||||||||
| Practice Location | |||||||||
| Address1: | 430 E DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | FOND DU LAC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 549354560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9209268332 | ||||||||
| FaxNumber: | 9209268370 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 02/25/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 0101235949 | VA | Y | Allopathic & Osteopathic Physicians | Hospitalist | 208M00000X | 60163 | WI | N | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 010086272 | 05 | VA | MEDICAID | 1000870001 | 01 | VA | DME PROVIDER | OTHER | 3810000340 | 01 | WV | WV MEDICAID | OTHER | 1821009838 | 05 | VA | MEDICAID | 9309526 | 01 | CIGNA | OTHER | P00193964 | 01 | RAILROAD MEDICARE | OTHER | 146132 | 01 | ANTHEM/BCBS | OTHER | 79389 | 01 | VA | OPTIMA | OTHER | 310269 | 01 | SOUTHERN HEALTH | OTHER |